Medical Practice Order Form

Practice Name

Prescriber's Name *

First

Last

Practice's email address

If we have your email address, you will get a copy of the requested items as confirmation

Patient Consent *

Please tick this box once patient has provided consent for us to receive their prescription and any non-prescription item requests.

Patient's Phone Number *

Prescription File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Click in the box and use your camera to take pictures of the patient's prescriptions or you can drag scanned images to upload.

Please select if you are recommending any non-prescription items for the patient